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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Number and social security number of each license applicant. <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />to advise you of the following regarding the use of this information: <br /> <br />1. This information may be used to deny the issuance, renewal or transfer of your <br />license in the event you owe the Minnesota Department of Revenue delinquent <br />taxes, penalties or interest; <br />2. Upon receiving this information, the licensing authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Information Agreement the Department of Revenue may supply this information <br />to the Internal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application, <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: Licjt~( Dr J C-iq,4tdtu NEW [ ] RENEWAL [~ <br />I 'J <br /> <br />LICENSING AUTHORITY: City ofCenterville <br /> <br />LICENSE RENEWAL DATE: c )4-<\ <br /> <br />1.01 <br />j <br /> <br />BUSINESS INFORMATION: <br />Business Name: [, )A+aJ6(,~S &ACJ" ("'~CL,1b ,TnC , <br />. <br /> <br />Business Address: };;) S? i ry\!+; v\ Sf.." <br /> <br />(C~(YtCf\/; 1\ t: rYlf) <br />[City] [State] <br /> <br />,-- - '3 <br />.)..~L) D <br />[Zip] <br /> <br />Business Telephone Number: <br /> <br />0L)/- L(~9-<u3 ~ <br />. - <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name:K ; ch A-(i'J A. 'De.f7~, c--. <br /> <br />. ------ <br /> <br />Title: +)r:::s / GlJner <br />,I <br /> <br />Social Security Number: <br /> <br />L/)'7-7{)--6:<150 <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name:'K;ChA-tcfA {jdv-c ~r1t,~i'dba LrJ,4-h::ir~tJ(' is &I.och Cj~vlJi I;,c <br />Business Address: ],;1 (f I rr7A-) t1 ,,56 ~/7 fCfL/j' /1 C 1J1/7 5:)tJ3't <br />